In Coding
Oct 7th, 2019
Don’t let insufficient documentation lead you astray. How many times has a provider asked you, “What do I need to document to get a 99215?” All too often, medical coders feel they should help their providers understand what elements of documentation are needed to warrant the higher level evaluation and management (E/M) service. Do not ...
In Coding
Sep 12th, 2019
It’s important to code with specificity the use of e-cigarette products. Too bad the ICD-10-CM code set falls short in this category. Six people have died from severe respiratory illness associated with use of vaping products in Illinois, Oregon, Indiana, Minnesota, California, and most recently, Kansas — all in the past few weeks. And there ...
In Audit
Sep 2nd, 2019
Ensure your organization receives credit for its chronically ill patients where credit is due. Requests for medical records come from many sources for different reasons. One reason is for quality assessment review of clinical documentation by contractors paid by the Centers for Medicare & Medicaid Services (CMS) for hierarchical condition category (HCC) and Healthcare Effectiveness ...
In Coding
Jun 20th, 2019
Social determinants of health (SDOH) will play a key role in quality reporting in the coming years. But until just recently physicians did not know the importance of capturing this data in their documentation, and vital diagnosis codes were not being reported. The American Medical Association (AMA) has created a free online education module to ...
Jun 17th, 2019
Over my almost 30-year surgical coding career, the documentation for assistant surgeons consisted of only the name of the assistant surgeon in the operative note header. Most often there was no mention of the role of the assistant surgeon in the body of the operative note; it was assumed the assistant surgeon provided an extra ...